This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Treatment of male sexual dysfunction with an internal or external penile prosthesis may be considered medical necessity when EITHER of the following is met:

• Erectile dysfunction is due to an organic disease or injury and is not psychological in nature; or
• There is failure, contraindication or intolerance to pharmacological therapy.

The following procedures and tests for the diagnosis of erectile dysfunction may be considered medically necessary:

• Comprehensive history and physical examination
• Lab tests for hormone levels of testosterone
  • Abnormal hormone levels may indicate further endocrine testing for pituitary, thyroid, and adrenal dysfunction.

Nocturnal penile tumescence (NPT) testing using the postage stamp test or the snap gauge test is rarely medically necessary. NPT may be considered medically necessary where clinical evaluation, including history and physical examination, is unable to distinguish psychogenic from organic impotence and any identified medical factors have been corrected. NPT testing using the RigiScan may be considered medically necessary only where NPT testing is indicated, and the results of postage stamp or snap gauge testing are equivocal or inconclusive. All other indications for NPT are considered not medically necessary.

The following diagnostic procedures are considered not medically necessary, and therefore are not covered, because spinal cord injury and other neurological deficits that may cause erectile dysfunction are typically identified during a comprehensive history and examination. These tests do not have any therapeutic implications and are, therefore, not medically necessary:

• Corpora cavernosal electromyography;
• Dorsal nerve conduction latencies;
• Evoked potential measurements.

The surgical implantation of an internal penile prosthesis may be considered medically necessary when the above criteria have been met and consideration has been given to a vacuum constriction device.

The removal of an internal penile prosthesis may be considered medically necessary for ANY ONE of the following indications:

• Infection; or
• Mechanical failure; or
• Urinary obstruction; or
• Intractable pain.

Following the medically necessary removal of an internal penile prosthesis, when benefit coverage is available for the internal penile prosthetic device, the surgical re-implantation of a medically necessary internal penile prosthetic device may be covered.

Penile revascularization, artery, with or without vein graft may be considered medically necessary for the treatment of erectile dysfunction when ALL of the following criteria are met:

• The individual presents with erectile dysfunction preceded by blunt perineal or pelvic trauma; and
• The individual has erectile dysfunction that is secondary to a focal arterial occlusion, as evidenced by an arteriogram or duplex ultrasonography conclusive for focal arterial obstruction; and
• There is no evidence of generalized vascular disease (e.g., diabetes mellitus, hypertension, coronary artery disease), Peyronie’s plaques, intracavernosal masses, nodules, or sensory neuropathy; and
• There is evidence of normal corporeal venous function; and
• Alternative nonsurgical treatment modalities have been fully explained to the individual, and the individual is determined to achieve spontaneous erections without the need for pharmacological, external, or internal support devices; and
• The individual is not actively smoking.

An external or internal penile prosthesis is considered not medically necessary for any other indication.

Venous ligation performed as a treatment for erectile dysfunction is considered not medically necessary.

The following may be considered medically necessary:

• Hormone injections (e.g., testosterone); or
• The Snap-Gauge device; or
• Vacuum constriction devices (e.g., ErecAid)

Diagnosis and Treatment of Male Sexual Dysfunction is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

• Link to Diagnosis Codes

• Link to References